TOP RANK NOTES | PSYCHIATRIC NURSING

BY: MS. JULES ARCEO, RN | REFRESHER PHASE – Stilted Using words or phrases that are Flowery words
ABNORMAL PSYCH language flowery, excessive, and pompous
NURSING CARE FOR PATIENTS WITH
Imitation or repetition of what the Repeats
PSYCHOSOCIAL ALTERATIONS Echolalia
nurse says OTHERS’ words

MENTAL HEALTH Repetition of the client’s own words Repeats OWN

Palilalia that is fast and decreases in words
state of wellness (emotional, psychological & social) as evidenced audibility
by
● satisfying interpersonal relationship
NOTE: If patient is coining new words, intervention would be to
● effective behavior and coping
clarify the meaning.
● positive self-concept
● emotional stability

MENTAL ILLNESS AFFECT

DEFINITION DISORDER
DISTURBANCE
disorders of mood, behavior & thinking
● causes significant distress/impaired functioning full range of emotional N/A (NORMAL)
Broad expression

SYMPTOMATOLOGIES IN PSYCHIATRIC CARE Flat NO emotional response Catatonia

Restrictive ONLY one emotion Paranoid (Fear)

THOUGHT
DEFINITION KEYWORD
DISTURBANCE Minimal emotional Major Depressive
Blunt response Disorder
Circumstantiality Patient answers in full, excessive Answers the
unnecessary detail but able to question, despites Emotions opposite to
◯ answer the question many words Inappropriate
situation
Schizophrenia

Labile Sudden shift of emotions Bipolar

Tangentiality Patient lacks focus; wanders off Many words, does
the topic and never provides NOT answer the
╱ information question
MOOD VS. AFFECT
Mood: Internal Feeling
Thought Belief that: others are putting ideas/thoughts into a
patient’s head Affect: External display of emotions
Insertion

Presence of rapid speech and Rapid Speech +

Flight of ideas patient jumps from one topic to Unrelated Ideas
MEMORY DEFINITION INTERVENTION/
another DISTURBANCE DISORDER

Looseness of Presents with fragmented ideas Anterograde Unable to create new

Unrelated Ideas Reorient the patient
with little to no relation to one Amnesia memories
association
another
Unable to recall past
Thought Belief that: others can hear/know what they are Retrograde Reminiscence Therapy
memories formed
broadcasting thinking Amnesia before onset of amnesia

Thought Sudden or abrupt stopping of ideas in the middle of Patient making stories to seen in Alzheimer’s
Blocking a thought fill up memory gaps Disease
Confabulation
(SYMPTOM) Clarify story with a
Thought Belief that: others are taking away the client’s significant other/someone
Withdrawal thoughts who was with them
during the event

SPEECH
DEFINITION KEYWORD BEHAVIORAL NURSING MANAGEMENT FOR
DISTURBANCE
PATIENTS WITH PSYCHIATRIC DISORDERS
Word Salad
Jumbled words and phrases that
Schizophasia Pure PATIENTS WHO ARE WITHDRAWN
are disconnected or incoherent
words/phrases

Ideas related to one another based Signs and Symptoms

Clang Rhyming
on sound or rhyming rather than
Association Words ● Aloof
meaning
● Alone
Patient creates new words that Coining new ● Catatonic
Neologism
only have meaning to them words ○ Priority for patients with catatonia: SAFETY;
Redirect to Activity
Perseveration Adherence to a single idea/topic Repetition of
even in attempts to change the topic TOPIC
Approach: Active Friendliness
Stereotyped repetition of phrases
Verbigeration that may or may not have meaning
Repetition of ● Activity → initiated by the nurse
PHRASES
to the listener ○ Achievable
○ Non-Competitive
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● Accompany the patient = Offer Self ● Confiscate dangerous items
○ Make patient feel someone is willing to spend time ● Observation
with them ○ Irregular Intervals = ↓ predictability of observations
● Appraise ○ Safest: one-on-one suicidal precautions; distance of
○ Make observations e.g. “I noticed that you..”
not more than 1m
○ Do NOT offer praises or material rewards
● Discharge
○ Provide list of suicide/crisis hotlines
PATIENTS WHO ARE DEPRESSED
○ Counsel the family about suicidal cues
Approach (SOME): Kind Firmness
MAJOR DEPRESSIVE DISORDER
● Therapeutic communication techniques (Silence & Offer Self)
● Motivate: Recalling previous achievements → reminds client of Mood Disorders (D C BBM)
their capability
● Engage in: Activities = HIGHLY STRUCTURED ● Bipolar I/Bipolar 2, Major Depressive Disorder
○ Scheduled ● Cyclothymia: fluctuating hypodepression & hypomania
○ Determined (↑ energy w/o hallucinations & delusions)
○ Directable ● Dysthymia: consistent hypodepressed
○ Achievable (w/o suicidal ideations)
○ Simple/Minute
NOTE:
- RATIONALE: Provide Distractions
○ BOTH Cyclothymia & Dysthymia can be diagnosed if symptoms
are persistent for 2 years
PATIENTS WHO ARE SUICIDAL

Suicidal Ideation
Disorder. ❌
○ If (+) Suicidal Ideations, it is considered as Major Depressive
DYSTHYMIA

● Suicidal Ideation: thoughts about killing/hurting oneself Risk Factors

● Active: (+) thoughts; (+) suicidal plans
● In women: Common
● Passive: (+) thoughts; (-) suicidal plans
● In Men: ↑ As ↑ Age
● Age: Equal risk in Adolescence
Manifestations (GCASH AL)
● Family: First Generation Relative e.g. mother
● Giving of valuables
● Canceling appointments Types/Causes
● Apologetic = Tying loose ends
● Exogenous (LDR):
● Sudden cheerfulness/ ↑ in energy ○ Loss
● Homicidal/Suicidal thoughts = “Twins of Depression” ○ Self Depreciation (criticize self)
● Actual/Imagined Loss ○ Self Reproach (blaming self)
● Endogenous:
Risk Factors ○ ↓ Serotonin
● Sex: ○ ↓ Norepinephrine
○ Attempt: Females
Criteria (DI WAGAS)
○ Death: Males
● Age: ● Difficulty thinking
○ Attempt: Adolescents ● Insomnia
○ Death: Older Adults ● Weight loss/Weight gain
● Civil Status: Single ● Anhedonia (loss of pleasure)
● Vices: Recreational Drugs/Pharmaceutical Drugs ● Guilt feeling
● Time/Day/Event/Sky: ● Anergia (loss of energy)
○ Early Morning ● Suicidal Ideation
○ Monday
Major Depressive Disorder: DI WAGAS + Impaired
○ During Endorsement
Functioning for more than 2 weeks
○ Gloomy Sky
Initial Sign: Sleeplessness
Management Hallmark Signs: Hopelessness, Helplessness, Worthlessness

Approach: Direct Confrontation

PATIENTS WHO ARE MANIC
Response to patient: Clarify the statement
Assess (LMS): Plan = Lethality, Method, Schedule Manifestations (HIT)
● Hyperactive
Nursing Interventions
● Impulsive
● Set a safety contract ● Talkative (flight of ideas)
○ Effective if a patient informs you if ↑ suicidal
ideations/↑ anxiety triggers
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 TOP RANK NOTES | PSYCHIATRIC NURSING
Hallmark Intervention: Limit Setting = Constantly Set ○ Environment: Time Out → Quiet, Safe Place
Firm Limits - Offer PRN Anxiolytic/Sedative
● Point out unacceptable behavior ○ If Uncooperative, show of force
● Inform client of expected behavior - Number: 4-6 staff members (for 4 limbs, 1 torso,
● Identify with the client consequences of repeated 1 head of patient)
unacceptable behavior - Leader: Nurse-In-Charge
C. Crisis
When manic phase is triggered: Put patient to a private ● Patient: Physical Aggression (to others, self & property)
room to ↓ stimuli ● Intervention: Seclusion & Restraints → patient loses right to
refuse treatment & confidentiality
Activities (GMA so NC):
● Seclusion
● Gross Motor Activities
○ Status of Consent: Required but SO signs
● Solitary
○ Purpose: Restorative
● Non Competitive
○ Goal: To regain self control
Diet: HIGH Calories; Finger Foods ○ Room Characteristics (LOS): Lockable,
Observable (from outside), Safe & Stimulus Limited
PATIENTS WHO ARE MANIPULATIVE ○ Monitoring: 1:1 for the the first hour

Manifestations ● Restraints
○ Doctor’s Orders: NOT required but must be
● Demanding
obtained within 1 hour
● Making a lot of requests
○ Status of Consent: Required
Hallmark Intervention: Set Firm Limits ○ Number of staff needed: 4-6 staff
○ Anchor on: stable part of the bed (NOT on side rails)
● Approach/Tone: matter-of-fact, calm & direct tone ○ Monitoring Frequency: Regular (every 15 mins.)
● Endorse to other staff members the limit set ○ Monitoring Status: Circulation/Skin
○ Duration of Restraints:
BIPOLAR DISORDER - Adults: 4 hours
The “mask of depression” - Children: 2 hours
● Main Problem: Depression - Children below 9 years old: 1 hour
● Main Manifestation: Manic ○ Temporary Removal: “Hourglass Pattern”
LUA → RLL → LLL → RUA
Biological Basis: ↑ Serotonin & Norepinephrine - Pattern: Alternating
- Duration: 10 mins.
Risk Factors
- # of Limbs: One at a time
● Sociocultural: Type A Personality - Frequency: every 2 hours
● Socioeconomic: Upper Class
NOTE:
Signs & Symptoms (FADE) ○ Quick-Release/Slip Knot is used to tie for restraints.
● Flight of Ideas ○ Make sure two fingers fit between the restraint and patient.
● Ang taas ng tingin sa sarili (Grandiosity) ○ Place restraints on the bed frame (on a part that moves up/down with the bed).
● Distractibility
D. Recovery
● Engage in Risky Activities & Sleeplessness
● Patient: Relaxation (Calmed Down)
Criteria for Diagnosis: FADE for at least 1 week ● Intervention: Assess the patient and others for injury
● Encourage to talk about the situation/triggers (debriefing)
PATIENTS WHO ARE ANGRY/AGGRESSIVE ● Assist to relax/sleep

Phases of the Assault Cycle E. Post-Crisis (Emotional Recovery)

● Patient: Reconciliary Action
A. Triggering
● Intervention: Formulate a plan of action ↴
● Patient: Non-Compliance
○ Encourage alternative actions if triggers occurs →
● Interventions: Ask patient to verbalize
approach nurse and verbalize feelings
○ Feelings: Acknowledge the feelings ● Do NOT lecture/chastise the patient
- Convey empathy ● Reintegrate to the environment
○ Statements: Clean, Simple, Short, Calm
○ Activity: Redirect to Physical Activities
PATIENTS WHO ARE PARANOID
B. Escalation
● Patient: Verbal Aggression Approach: Passive Friendliness
● Intervention: ● Manner: Formal/Businesslike with simple, direct & concise
○ Voice: Calm but Firm words
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Interventions (DISARM) ● Tactile (Touch): seen in alcohol withdrawal →
● Develop Trust (Congruence & Consistency e.g. aligning words to formication = insects crawling in the body
your actions) ● Olfactory (Smell): most common in seizures or
● Involve the client in planning schizophrenia = phantosmia
● Sealed Container for food/medications → patient will open own food/meds ● Gustatory (Taste): common in seizure (aura) → has
● Avoid whispering/giggling/staring at the patient metallic/rusty taste
● Respect personal space (1 m/4 ft away) ● Cenesthetic: feeling undetectable body functions e.g. feels
bone marrow making RBCs, feels neurons
NOTE: Ask permission if needs to violate personal space ● Kinesthetic: feeling movements while motionless
e.g. during vital signs ● Synesthesia: mixing of senses e.g. seeing sounds, tastes colors

● Maintain professional tone Interventions (HARDER)

● Hallucinations must be recognized → as patients does not
PATIENTS WITH DELUSIONS
directly tell that they are having hallucinations
Definition: False, Fixed Belief ● Assess the content e.g “what are you seeing at the wall?”
● Reality presentation
TYPES
● Divert attention
● Grandiose: superiority, invulnerability, high status
● Persecutory: others are planning to harm the patient To present reality & divert attention,
● Somatic: unrealistic health/body beliefs = abnormal body ○ call client by name
○ refer to day, time & environment
functions
● Nihilistic: non-functioning/rotting/disfigured/misshapen ● Engage in reality-based activities
organs ● Reintegrate to environment e.g. group therapy
● Erotomanic: someone is in love with them ○ Talking with others with the same experience lessens
● Ideas of Reference: general events are about them feeling of isolation & loneliness
● Religious: second coming of a religious figure = appears
ONLY during psychosis Other Interventions
● Sexual: sexual behavior is known by others
● For Auditory Hallucinations: Talk back to the voices
Interventions (CAVE) ● Hallucinations and Anxiety: ↑ Anxiety = Hallucinations
○ Identify situations on events that trigger anxiety
● Initial Intervention: Clarification of meaning ○ Use relaxation/anxiety-reducing techniques
● Acknowledge/Validate feeling behind delusion
○ ❌ DO NOT “CAR”
e.g. deep breathing, guided imagery, music therapy, journaling

- Confront patient threateningly SCHIZOPHRENIA

- Argue
● split mind = experience break down in the relationship of
- Reinforce the delusion
○ ✔️Use simple statements
thoughts, emotions & behavior
● Former Term: Dementia Precox
● Voice doubt by presenting/maintaining reality
● Engage in reality-based activities e.g. going to garden, joining to
group activity Risk Factors
● Genetics
PATIENTS WITH HALLUCINATIONS ○ 1 parent = 15% chance
○ 2 parents = 35% chance
ILLUSIONS VS. HALLUCINATIONS ● Socioeconomic: ↓ Socioeconomic Status → less access to health care

● Hallucinations: misperceptions NOT based on reality e.g. ● During Pregnancy

seeing snakes on the floor ○ Tobacco Smoking
● Illusions: misperceptions based on reality e.g. seeing wire as ○ Alcohol
snack ○ Stress
● Addressing Illusions: Clarify Reality ○ Malnutrition
○ During 2nd Trimester, had Influenza
When presenting reality, in:
○ Illusions: patient will immediately believe you as they will
suddenly realize it Biological Basis
○ Hallucinations: patient will find it hard to believe ● Neuroanatomical Manifestations: ↓ CSF & Brain Tissue
● Neurotransmitters: ↑ Dopamine and Serotonin
TYPES OF HALLUCINATIONS
● Auditory (Hear): most common Criteria for Diagnosis
○ Command: most dangerous 2 or more Hard/Soft Symptoms for at least 1 month
● Visual (Sight): second most common e.g. taking marijuana
= kaleidoscopic vision
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Positive/Hard Symptoms ● Discontinuation: Taper dosages to avoid rebound anxiety

CAUSE: ↑ Dopamine Levels

● Diet: ❌
Alcohol and other sedatives → causes CNS depression
● Antagonist for Toxicity (Antidote): Flumazenil
● Ambivalence: contradictory beliefs/feelings about a
person, events or situation Levels of Anxiety
● Echopraxia: imitation of movements of other people
● Bizarre Behavior: outlandish behavior/appearancel;
LEVELS OF ANXIETY
repetitive action; unusual social/sexual behavior
● Looseness of Association LEVEL PERCEPTUAL FIELD BEHAVIOR
● Delusion
● Flight of Ideas Motivated with
MILD Wide
fidgeting
● Hallucinations
● Ideas of Reference Narrowed to Immediate Task
MODERATE Cannot connect thoughts on Increased Fidgeting
● Preservation
own → patient starts to need assistance

Negative/Soft Symptoms Cries

SEVERE One detail or scattered details Ritualistic
CAUSE: ↑ Serotonin Levels Feels Horror

● Alogia: poverty of speech/content (mutism) Irrational/ Delusions/

● Anhedonia: loss of pleasure PANIC Cannot process anything Hallucinations/
→ patient is completely dependent Suicidal
● Apathy: indifference
● Asociality: socially withdrawn (either few to no relationships)
● Catatonia: physiologically-induced immobility
PHYSICAL NURSING
● Avolition: absence of will, ambition, motivation LEVEL
RESPONSE INTERVENTIONS
● Inattention
● Blunt/Flat Affect MILD General: Restless Little to NO interventions
“EXCITED” Sleep: Difficulty Acknowledge/Verbalize
GI: Butterflies Feelings
TYPES
MODERATE Pulse: Increased Focus: Redirect/Refocus the
DSM-IV “NATATAE” Skin: Diaphoresis patient
● Catatonic: catatonia/waxy flexibility Mouth: Dry Sentences (SSE): Slow,
GI: Upset Simple & Easy to Understand
● Disorganized: bizarre thoughts/behavior GU: Increased Urination Anxiolytics: Oral
● Paranoid: suspicion/delusions Speech: Rapid Speech
Pitch: High-Pitched
DSM-V Muscles: Tension

● Brief Psychotic Disorder: at least 1 psychotic symptom SEVERE Head: Severe Headache Remain with the client
<1 mo. “HINDI Skin: Pallor Voice: Soothing, Calm
NAG REVIEW” GI: Nausea, Vomiting Address: Physical Symptoms
● Schizophreniform: symptoms are >1 mo. but <6 mos.
& Diarrhea Anxiolytics: IM
● Shared Psychotic (Folle A Deux): friend/close Heart/Chest: Palpitations
relationship of schizophrenia develops the disorder & Chest Pain

● Schizoaffective Disorder: psychotic disorder + mood PANIC Three Fs: Flight, Fight, Take control by putting them
disorder Freeze in quiet, non-stimulating
room

Signs PRN: Restraints (if pt. is hurting self)

● Initial Early Sign: lack of interest in school/work

EATING DISORDERS
● Other Signs: Self-Neglect (Hygiene)
Risk Factors
ANXIETY ● Age: Adolescents (18-24 Y/O)
● General or specific = General Feeling ● Biological Basis: ↓ Serotonin & Norepinephrine
● Immediate or non-immediate threat = Non-Immediate ● Psychodynamics: Experience Parental Harassment/
● Known or unknown source = Unknown Source Overprotective Parents
● Biologic Basis: Lack of GABA (Gamma Amino Butyric Acid) ● Sociocultural: Developmental Pressure

Fear: Specific Feeling, Immediate Threat & Known Source ANOREXIA NERVOSA
● life-threatening disorder
Drug of Choice ● Nutritional Intake: Restricted
● Intense Fear: Gaining Weight/Looking “Fat”
● DOC: Benzodiazepines (-lam, -pam) → sedative
● Refusal: Acknowledge the seriousness of disorder
● Concerns/Side Effects: Late Onset
● Perception: Disturbed Body Image
○ Onset of Effect: 4-6 weeks after
● Duration: At least 3 months
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Other Manifestations Nursing Interventions for Bulimia Nervosa
● Behavior: Perfectionists ● Eating with: Significant Others e.g. family
● Exercise: Compulsive Exercising ● Eating at: Dining Room/Table
● Calories: Count Calories ● Eating plan: Consists of Nutritious Food
● During Eating: Ritualistic Behavior e.g. crushing food so they ● Avoiding Food: That is consumed during binges
won’t feel it’s a lot ● Moving Food: That is NOT at kitchen/dining area
● Everyday Activities: Preoccupation with Food
● Knowledge on Food: Knowledgeable
● Insight: Lacks Insight

Complications
● Hair: Alopecia
● RBCs: Anemia
● Skin: Lanugo (serve as heat preservation due to lack of subcutaneous fat)

TWO TYPES
● Restrictive Anorexia Nervosa
● Binging-Purging Anorexia Nervosa

General Interventions for Eating Disorders

(BOTH Anorexia & Bulimia)

● Schedule: Plan meals with client

● During Meals: Set Limits
● After Eating: Supervise for 1-2 hrs (WOF Vomiting)
● Social Media: Limit Time
● Psychotherapy: Self Monitoring through a food diary

Specific Interventions for Anorexia Nervosa

● Specific Meal Schedule: 3 meals & 3 Snacks with Liquid
Protein → liquid protein is needed to meet nutritional needs especially if
previous meals were not consumed much
● In-between meals: Give Supplements
● In performing food rituals: Discourage → setting limits
● Weight: Daily Weight Monitoring

BULIMIA NERVOSA
● Cycles: Hunger-Anger Cycle
● Syndrome: Binge-Purge Syndrome
○ Purging Behaviors:
- Self: Self-Induced Vomiting → stimulating the uvula
- Misuse (LED): Laxatives, Enemas, Diuretics
○ Duration: Once a week for 3 months

NOTE: Hunger-Anger Cycle & Binge-Purge Syndrome is precipitated

by strong emotions

Signs & Symptoms

● Hands: Russell's Sign

Russell's sign: pattern of calluses on the knuckles or back of

the hand due to frequent purging (via self-induced vomiting)
over a long period of time.

● GI: Rectal Bleeding (due to consistent use of enemas)

● Tooth: Decay
Electrolytes: ↓ K → can cause dysrhythmias
✔️
●
● Insight: (+) Insight = Aware → but ashamed of behavior, thus, eats privately
● BMI: Normal/Overweight

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